Patient Registration Form
Full Name:
Your answer
DOB:
Your answer
Address
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E-mail:
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Home Phone Number:
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Mobile Phone Number:
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Employer:
Your answer
Occupation
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GP Name:
Your answer
GP Practice:
Your answer
Which service are you coming to us for:
Required
It is important that you understand the assessment and treatment you are coming for in order to give your full consent to participate. By signing this form you confirm that you understand the treatment process, understand you may be required to undress and may be physically examined by your therapist. Please be aware that you can change your mind at any time. Your therapist will ensure that you are informed of what is happening over the course of the treatment.
If you have been referred to us by an insurer, GP, solicitor, agency, employer or anybody else that is funding your treatment then it is likely that they wish to know what is found during the assessment and the progress being made with treatment. Please sign below that you are happy for us to share this information. If you require a copy of the report please tick below:
Required
I have read and understood the provided information booklet and understand what the treatment is likely to involve, the benefits and the potential risks.
Full Name
Your answer
Date
Your answer
All of your personal records are confidential and we will never share your details with anyone else. We will use the details that you provide to us to contact you via e-mail/letter/telephone/text in relation to any appointments that you have with us and to share any important information with you.We may from time to time contact you via email with special offers and information that we think may be useful. If you do not wish to be contacted in this way please tick here
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